BISMARCK — North Dakota is in a bad way with coronavirus.

It’s certainly no secret — the state has led the nation in new COVID-19 cases per capita for most of the last two months as the virus has permeated through communities big and small.

November is on pace to be by far the deadliest month of the pandemic, and most public health experts say the outbreak will likely get worse before it gets better.

Los Alamos National Laboratory’s projections for the state predict between 322 and 808 more COVID-19 deaths by Dec. 30, adding to the 840 residents who have succumbed to the virus since March. Recently, the laboratory’s worst-case projections have been the most accurate for North Dakota.

But the doom and gloom of the last eight months has been cut by a piece of very good news. The whole nation could be on the brink of major relief from the ruthless virus after two leading pharmaceutical companies released promising preliminary data from their vaccine trials earlier this month.

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North Dakota hospitals and nursing homes have been pummeled by the virus, but experts in the state are excited about the possibility that health care workers and long-term care residents could have at least partial immunity to COVID-19 within the next four months. A little further down the line, the vaccine could give enough residents immunity to return the state to a pre-pandemic normal.

In the meantime, the extent to which North Dakota’s outbreak worsens or improves is up to the people of the Peace Garden State, epidemiologists say. If residents wear masks, wash their hands and stay away from social gatherings, the state can wrangle the virus under control and preserve hospital capacity. If they continue to ignore the proven public health measures, the state is in for a hellish winter.

“I’m very afraid we’re going to lose a lot of people needlessly,” said state Field Medical Officer Dr. Joan Connell.

Actions and consequences

As Connell sees it, there are some avoidable consequences of the pandemic if North Dakotans take the right steps and some inescapable scars that will become visible over the next few months.

She worries the state’s outbreak will leave mental trauma in its wake the same way a natural disaster does. But unlike a calamitous hurricane or tornado, the pandemic is a dull and enduring state of agony, she said.

Many front-line workers, like nurses and doctors, will end up with post-traumatic stress disorder from the long days and nights of fighting in the trenches against the virus, she said. Ordinary citizens dealing with the daily stress brought on by the pandemic, including children forced to think about harsh realities, could suffer lasting blows to their mental health, too. She added that some of the mental anguish could be averted if North Dakotans turn their act around and start taking mitigation measures seriously.

But most of all, Connell is troubled by the idea that a moment of reckoning is coming for every resident of the state who survives the outbreak, and the ensuing guilt will be a heavy load to bear.

“You can’t choose where the hurricane lands. Our society in North Dakota is choosing to not wear masks, not socially distance and continue to participate in congregate settings,” Connell said. “My biggest concern is when people realize their role in what they did or did not do to prevent needless death and how that is going to affect our psyche for the rest of our lives. That keeps me up at night.”

Connell notes that in addition to the mental toll of the pandemic, the long-term health effects of COVID-19 are not fully understood due to the novelty of the illness. In rare cases, people classified as “recovered” from the illness, including those who had barely any symptoms, reported serious cardiovascular, respiratory, renal and neurological issues, according to the Centers for Disease Control and Prevention.

Even with some pain yet to come, Connell said there are specific actions North Dakotans can take, like hand-washing, mask-wearing and social distancing, to improve the state’s unstable position with the virus.

Slowing the spread of COVID-19 won’t be as easy as it would have been over the summer because the state’s cold winter weather means residents will be confined to indoor spaces where the virus spreads more easily, Connell said.

Even small and medium-sized gatherings, like in-person business meetings, have become dangerous spreading events due to the widespread community transmission of the virus, said state field epidemiologist Brenton Nesemeier. Meanwhile, weddings and funerals held in the last few months have proven to be “superspreader” events.

North Dakota saw a bump in cases after Halloween festivities, and experts like Nesemeier fear Thanksgiving and Christmas gatherings could throw the state further into the grips of the virus.

State epidemiologist Grace Njau said the situation with COVID-19 could get “very much worse” if families across North Dakota host multigenerational holiday dinners with members of several different households.

“We really all ought to play our part. And realize the chain events of how a dinner (small or large) can expose an individual who then exposes a family member who then exposes a school teacher whose spouse is a healthcare worker who then introduces the infection to a (long-term care) facility,” Njau said in an email.

Njau said infection data suggest that in a group of five randomly selected North Dakotans, there’s a 14% chance at least one has COVID-19. In some parts of the state, like Grand Forks and Minot, that risk is even higher.

That’s why Nesemeier and Njau are calling on residents to keep Thanksgiving and Christmas gatherings to just their own household. Nesemeier also encouraged college students, who have higher-than-average infection rates, to stick around campus over the holidays.

“By taking a small step this year and spending it amongst your immediate, intimate family, we can ensure that for future holidays and future events you can have a larger gathering,” Nesemeier said.

If North Dakotans ignore the advice, Nesemeier said residents seeking medical attention at hospitals could see long wait times for basic medical procedures as the health care system cracks under the pressure of staffing shortages and rising admissions. COVID-19 deaths would also increase as older family members catch the virus, Njau said.

Nesemeier and Njau remain hopeful that North Dakota's new mask requirement, announced Nov. 13, will increase mask-wearing and help prevent some spread of the virus. However, both noted that the effectiveness of the mandate won’t be known for another seven to 21 days.

Brenton Nesemeier, a field epidemiologist with the North Dakota Department of Health, takes part in a Red River Valley COVID-19 Task Force meeting on July 15 in Fargo City Hall. Michael Vosburg / Forum Photo Editor
Brenton Nesemeier, a field epidemiologist with the North Dakota Department of Health, takes part in a Red River Valley COVID-19 Task Force meeting on July 15 in Fargo City Hall. Michael Vosburg / Forum Photo Editor

Njau said she expects rising case figures and hospitalizations in the weeks immediately following the mandate to create “a deceptive effect to the public of assuming that 'masking doesn’t work' while in actuality we would just be tackling the aftermath of the cases and new transmissions that happened before the order was in place.”

Dr. Stephen McDonough, a Bismarck pediatrician and former senior state health official, said the work to promote masks is not done just because they’re now required in public places.

He said the state needs to get 95% of the population wearing masks to curb the spread of the virus. He recommends an aggressive public education campaign focusing on the benefits of proper mask-wearing.

“There’s too much happy talk with the mask education that’s going on,” McDonough said. “The reasons why people should wear a mask aren’t being stated.”

The CDC and other experts say masks help to prevent spreading the virus and also protect the mask wearer.

McDonough noted that leaders should focus on the direct line between wearing a mask and protecting the state’s health care workers and nursing home residents. If North Dakotans begin to understand how their unwillingness to wear a mask is responsible for the rise in COVID-19 deaths and lack in hospital capacity, they may be more inclined to get on board with the public health measure.

Nesemeier stressed that just because the state now has a mask mandate doesn’t mean other mitigation measures, like avoiding large gatherings, can be disregarded. All of the pieces of the puzzle need to fall into place for the state to see a dip in new infections, he said.

Echoing hospital administrators, Connell said North Dakotans should also continue to seek routine outpatient medical care instead of putting it off until the outbreak dies down. She said deferred doctors’ visits could mean more hospitalizations down the road, which only sustains the strain on the health care system.

Nurse Paige Wilen works in the emergency department at Jamestown Regional Medical Center on Nov. 15. Jamestown Regional Medical Center / Special to The Forum
Nurse Paige Wilen works in the emergency department at Jamestown Regional Medical Center on Nov. 15. Jamestown Regional Medical Center / Special to The Forum

Hope on the horizon

For the first time since March, there’s an end in sight for the worst of the pandemic.

Drugmakers Pfizer and Moderna announced earlier this month they had independently developed COVID-19 vaccines that appeared to be about 95% effective in late-stage clinical trials. North Dakota Gov. Doug Burgum said the news represents "a very bright light at the end of the tunnel" as he encouraged residents to hunker down until the highly anticipated remedy arrives.

The results are still preliminary and neither vaccine has yet gained emergency approval from the U.S. Food and Drug Administration, though Pfizer submitted its vaccine application to the agency on Friday, Nov. 20, and a green light for mass distribution could come in mid-December.

North Dakota immunization program manager Molly Howell said residents should be “cautiously optimistic” about the latest developments in the path to a vaccine. Several other high-powered pharmaceutical companies are also in late-stage vaccine trials that could yield more immunization options.

Vials with a sticker reading "COVID-19 Coronavirus Vaccine" are seen in front of a Moderna logo. Moderna Inc. announced that its experimental COVID-19 vaccine is about 95% effective based on initial trial results. Pfizer Inc. has made a similarly promising announcement.  Dado Ruvic / REUTERS
Vials with a sticker reading "COVID-19 Coronavirus Vaccine" are seen in front of a Moderna logo. Moderna Inc. announced that its experimental COVID-19 vaccine is about 95% effective based on initial trial results. Pfizer Inc. has made a similarly promising announcement. Dado Ruvic / REUTERS

Howell said she was pleasantly surprised by the reported level of effectiveness of Pfizer and Moderna’s vaccines, noting that the FDA’s bar to clear was just 50%. If both vaccines really are 95% effective, it would put them on par with some of the most reliable immunizations available, like the chickenpox vaccine, she said.

The timeline for Americans receiving COVID-19 vaccines is not fully fleshed out, but North Dakota submitted its vaccine distribution plan to the CDC last month and continues to fold in recommendations from the agency.

Howell said she expects health care workers and nursing home residents to receive their first of two doses as soon as the beginning of next year. The vaccine could then begin providing immunity a few weeks after the second dose.

Since the supply of doses will be limited after the vaccines are approved, the general public will likely have to wait a few months to get their immunization. Howell said there’s potential for widespread distribution of the vaccine as early as April of next year.

Due to a massive influx of federal funding, companies have developed COVID-19 vaccines in record time. In an unusual step to speed up the distribution process, mass manufacturing of the vaccines is already underway even though the immunizations haven’t yet been approved.

North Dakota bought four ultra-cold freezers in anticipation that some COVID-19 vaccines may require far-below-freezing temperatures for storage. North Dakota Department of Health / Special to The Forum
North Dakota bought four ultra-cold freezers in anticipation that some COVID-19 vaccines may require far-below-freezing temperatures for storage. North Dakota Department of Health / Special to The Forum

North Dakota bought four ultra-cold freezers and nine transport coolers in anticipation that some versions of the vaccine would require far-below-freezing temperatures while in transit. Pfizer’s vaccine must be kept in ultra-cold conditions while Moderna’s can be transported in regular frozen storage.

Once a vaccine is approved and widely available, health officials hope to inoculate enough of the country’s population to ensure herd immunity.

Experts like Howell reject the idea of achieving herd immunity solely through people contracting the virus because about 70% of the population would have to survive the infection and the human toll would be enormous.

However, a widely available vaccine combined with the immunity gained by those who have been infected could get the nation to herd immunity fairly quickly. Howell said North Dakotans are about average in their willingness to receive vaccines compared with the rest of the nation, but the campaign to promote the COVID-19 vaccine will have to convince the skeptics.

Howell noted that mask-wearing and social distancing will be essential until at least late next year, but a post-pandemic world isn’t just a pipe dream anymore.